HPI: Patient had been experiencing painful cramping associated with menstruation since December 2012.

In June and July, patient had no period.

In August, experienced light spotting which lasted for 2 weeks.

LMP began 9/23 and has continued since - now on day 10. Associated with extremely heavy bleeding and intense abdominal pain. Patient states that she has used 3 boxes of tampons and is waking up 3+ times a night due to bleeding through pad.

Patient did not want to be admitted although a hysteroscopy was scheduled for the following morningStructural Causes:PolypAdenomyosisLeiomyomaMalignancy & hyperplasiaLaboratory Tests and Imaging Answer - BImportant to rule out malignancy Endometrial sampling is indicated in patients older than 45High overall accuracy Hysteroscopy - good for diagnosis of cancer but not hyperplasia

SocHx: Works at a research firm. Lives at home with husband, all three children out of the house. Denies tobacco use, drinks 3 glasses of wine per week. Medical History Physical ExaminationObesity, signs of insulin resistance, thyroid disease, or PCOSSigns of bleeding disorder Pelvic examinationExternalSpeculum Bimanual A 50-year-old G2P2 has a history of menorrhagia, pelvic pain, dyspareunia, dysmenorrhea, constipation and occasional spotting in between periods. She has a three-year history of urinary urgency and frequency. The patient is concerned that she has fibroids, as her close friend was recently diagnosed with fibroids. What is the symptom most commonly associated with leiomyomas?

A. Intermenstrual spotting (metrorrhagia) B. Menorrhagia C. Dyspareunia D. Dysmenorrhea E. Urinary symptomsThe major symptom associated with myomas is menorrhagia, thought to be secondary to: 1) an increase in the uterine cavity size that leads to greater surface area for endometrial sloughing; and/or 2) an obstructive effect on uterine vasculature that leads to endometrial venule ectasia and proximal congestion in the myometrium/endometrium resulting in hypermenorrhea. Other relatively frequent symptoms include pain and pressure symptoms related to the size of the tumors filling the pelvic cavity, as well as causing pressure against the bladder, bowel and pelvic floor.Laboratory TestingPregnancy testCBC - w/platelets, PT and aPTTTSHPap smearImagingTransvaginal ultrasoundSonohysterography Hysteroscopy Anovulatory cycleOCPPregnancyPelvic infectionTumorCoagulopathy Ages 13-18Ages 19-39PregnancyPolyps, myomasAnovulatory cycleOCPEndometrial hyperplasiaAnovulatory cycleEndometrial hyperplasia/CAAtrophyMyomas40-menopauseA 49-year-old G0 reports that her periods have become heavier over the last year. The patient’s physical exam is notable for her having a slightly enlarged, irregularly shaped uterus. A pelvic ultrasound confirms the presence of two 2 x 2 cm intramural uterine fibroids. The patient’s friend recently had a hysterectomy due to uterine fibroids and menorrhagia. The patient would like to avoid having surgery. She has tried NSAIDs which did not seem to help much. Her endometrial biopsy is negative. She is interested in the medical options for treating symptomatic uterine fibroids. What is the next best step in the management of this patient? A. Aspirin B. Methotrexate C. Estrogen D. Gonadotropin-releasing hormone agonists E. IndomethacinAnswer - D Growth of uterine fibroids is stimulated by estrogen. Gonadotropin-releasing hormone agonists inhibit endogenous estrogen production by suppressing the hypothalamic-pituitary-ovarian axis. They can result in a 40-60% reduction in uterine size. This treatment is commonly used for three to six months before a planned hysterectomy in an attempt to decrease the size of the uterus, which may lead to a technically easier surgery and decreased intraoperative blood loss. In patients who are not yet menopausal, once the gonadotropin-releasing hormone agonist therapy is discontinued, the fibroids may grow again with re-exposure to endogenous estrogen. Thus, this therapy may be most useful for women who are close to menopause, as this patient is at age 49. Aspirin and Methotrexate are not effective treatments for fibroids. Methotrexate is used in ectopic pregnancies. Aspirin and Indomethacin will likely not help, as she did not respond to NSAIDs.A 50-year-old G3P3 complains of menorrhagia. Physical examination is notable for a 14-week size irregularly shaped uterus. Her hematocrit is 35%. Which of the following is the next most appropriate step in this patient’s management?The majority of patients with uterine fibroids do not require surgical treatment. If patients present with menstrual abnormalities, the endometrial cavity may be sampled to rule out endometrial hyperplasia or cancer. This is most important in patients in their late reproductive years or postmenopausal years. If the patient’s bleeding is not heavy enough to cause iron deficiency anemia, reassurance and observation may be all that are necessary.

Treatment with GnRH analogue can also be used in perimenopausal women as a temporary medical therapy until natural menopause occurs.

Particularly in a perimenopausal woman, it is important to first rule out an underlying endometrial malignancy with endometrial sampling.A. Hysteroscopy B. Endometrial sampling C. Treatment with GnRH analogue D. Hysterectomy E. Myomectomy